GW1-2021-05930_Well Construction - GW1_20211115

CONSTRUCTION RECORD(GW_1) For Internal Use Only:
I.Well Contractor Information:
�Sfl i V hou M WATER ZONES
Well Contractor NameO� FROM I TO DESCRIPTION
ft. :L o. ft. 0 rA
ft. go k, CS f
NC Well Contractor Certification Number 15.OI1TER CASING for mDid-me w OR LINE a ble.
h a CID FROM TO DIAMETER TMCKNESS MATERIAL
•�' q' ft. ft. in. a
Company Na P I'Tf 1. ! _..
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: G r 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well aonsawction permits(i.e.U1C,Counp•,State,VaNt' Ice,etc.) fL dL to.
3.Well Use(check well use): ft' R. is
Water-Supply Wen: FROM REENTO DIAMETER SLOT SIZE THICKNTM MATERIAL
Agricultural unicipaUPublic ft. ft. Ia.
Geothermal(Heating/Cooling Supply) Vcsidcritial Water Supply(single). fL it. in.
Industrial/Commercial. [3Residentiai Water Supply(shared) IS GROUT
H ation FROM TO MATERIAL EMPLACEMENT METHOD&AM0UNT
Non-Water Supply Well: 0 ft & cA
Monitoring .Recovery ft. fL
61
Injection Well: % &
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ►icable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL F.MPGACEMETVT METHOD
Aquifer Test C)Stormwater Drainage R• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LUG tattach.adtfidoWa7l shieb eZessprrb
Geothermal(Heating/Cooling Return) r3Other lain under#21 Remarks FROM I To DERit'TiON color,hardness,sotllrock rain size,etc.
0 �`' 1 o ft. SC
C J Qin
4.Date Well(s)Completed: D! ��' 1 I Well W# R k' r t�t (/ I<'
cn 'Wep _at!cv:
M b rw c k �a Yh eS V1 ��
Facilitv/0wner Name Facility 1D#(if aaplicablel R• R• ND V.5Qu-Fol-�h �tr. P, sl�t��� a73�a ft ft. 0?t
Physical Address.City.and Zip ft. ft. / 0�/�S
CQ� Q)4 21.RE R"
County Parcel Identification No.(PIN) AS rr� '� I vie r � 00 (J rooffG
10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0 7 h e I tAlrob u 0
(ifwell field,one lat/long is sufficient) 22.Ce Cation: /, Q
6.Is(are)the well(s)dWrmanent or OTemporary SignatV of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EfNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
rrrh.a 1.n sonnia•Fll met A——11 rnneMrrtinn infnr.nnfinn.nvt arnlntn rho nnhno n rap copy of this record has been provided to the well owner.
repair under#21 remar&section or on the Lack o)IhiS form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
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«•u •A SUBMITTAL INSTRUCTIONS
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wnsrruclwn W the toiiuwmg:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing•,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: o (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Weil construction method: air (rt7 G'r�' above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) _7
construction to the following:
�,z•v a Tnn cr•tena {�a�ms a e<an a•. f Division of Water Resources.Underground Injection Control Program,
blow
13a.Yield(gpm) Method of test: 24c.For Water SunDiv&Inieetton Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4 Amount: completion of well construction!to the county health department of the county
where constructed
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016